UTERINE CAVITY EVALUATION PRE IVF IS A MUST THIS PRESENTATION DISCUSSES WITH EVIDENCE HOW WE SHOULD GO ABOUT

1. PROF.JAIDEEP MALHOTRA
MD,FRCOG,FRCPI,FICS,FICOG,FICMCH,FIAJAGO.FIUMB,FMAS.
 Managing Director ART Rainbow IVF at Agra.
 Prof. Dubrovinck International University, Croatia
 President elect FOGSI 2018
 President elect of SAFOMS
 Vice President ISAR
 Vice President ISPAT
 Imm President ASIA PACIFIC INITIATIVE ON REPRODUCTION2014-16
 Imm past President Indian Menopause Society 2016-17
 Member FIGO committee of Reproductive medicine 2015-2018
 Member FIGO Working Group on Reproductive &Developmental Environ Health
 Editor SAFOG Journal
 Editor SAFOMS Journal
 Vice Chairman Indian College of Obs and Gyn 2015-16
 Secretary Indian Menopause Society 2014-15
 Vice President FOGSI 2010
 Chairperson International Academic Exchange Committee FOGSI 2002-2007
 Indumati Zhaveri Award, Jagdeshwari Misra Award three times, Ethicon Fellowship,
Outstanding Achievement Award 1999, Chorion Award
 Co-editor of step by step series of books
 Co-editor of manual of operative obs gyn
 Editor of “Fetus Our Other Patient”,& “Managing Infertility in low resource”
 Credited with producing firsts of U.P. : IVF birth, ICSI birth, IVF Twins, ICSI Twins,
IVF Triplets, TESA-ICSI Pregnancy etc.
 Credited for producing first Three hundred Test Tube Babies of Nepal
 Consultant IVF specialist :Maulana azad medical college Delhi &S MS
medical College Jaipur, J.N Medical college Aligarh.
 Consultant IVF specialist at : Ludhiana, Ambala, Gwalior, Gorakhpur, Delhi,
Bhiwani, Barielly, Allahabad, Kolkatta, Dhanbad, Kathmandu & Dhakka

2. Pre IVF Hysteroscopy
Prof Jaideep Malhotra
MD,FRCOG,FRCPI,FICOG,FMASI.

3. • Why evaluate cavity pre IVF ?
• Methods to evaluate cavity ?
• Comparison of diff methods
• Indications of hysteroscopy
• Impact of hysteroscopy

4. Why cavity evaluation?
• Prevalence of one or more
intrauterine abnormalities in
asymptomatic women
undergoing office
hysteroscopy prior to IVF first
cycle : 11 %
Uterine cavity abnormalities are
seen as a cause of infertility in
around 10%-15% of women. In
women with recurrent implantation
failure abnormalities are found in
up to 50% of the women.
Pundir and El-Toukhy, 2010.

5. • This fact necessitates accurate
evaluation of the uterus before
proceeding to ART.
• Transvaginal ultrasound (TVS),
sonohysterogram,
hysterosalpingography (HSG), and
hysteroscopy (HS) are the most
commonly used methods for this
purpose.

6. HSG vs HS
• HSG is a safe and simple technique for
indirect evaluation of not only the uterine
cavity but also the fallopian tubes.
• Generally, HS is used as an adjunct to
one or more of the others rather than as
a basal investigation.
• It provides direct visualization of the
uterine cavity together with the cervical
canal and permits therapeutic
intervention if necessary without causing
remarkable patient discomfort.

7. • The accuracy of HSG in assessment
of the uterine cavity integrity in
infertile patients has been reported
to be rather disappointing.
• The sensitivity and specificity are
described to be 79–98% and 15–
82%, respectively (Gaglione et al.,
1996; Golan et al., 1996).
• The pathologies that HSG most
commonly missed were uterine
septum/subseptum, endometrial
polyps, submucous myoma, and
Asherman syndrome.

8. When we have such modalities
available…..

9. ASHERMAN’S SYNDROME
ASHERMAN’S SYNDROME

10. TVS vs HS
• Where hysteroscopy is considered to be the gold standard,
the sensitivity, specificity, positive and negative predictive
value for TVS in detecting cavity abnormalities were all
reported to be between 81 and 100% .
Ayida et al., 1997; Shalev et al., 2000.
• Intrauterine adhesions may be the most difficult to
diagnose at TVS.
• In fact, uterine subseptum seems to be overdiagnosed in
HS, possibly owing to inadequate distention of the uterine
cavity or the surgeons’ tendency to intervene to achieve a
larger and smoother uterine cavity before progressing in
IVF.

11. The debate goes on…
Is it a money making gimmick ?
• One of IVF's long-running controversies - whether the
outcome for women can be improved by routine
hysteroscopy performed before further IVF treatment.
• The position of hysteroscopy in the management of the
infertile female remains under debate. Although a
variety of studies demonstrate that the procedure is
well tolerated and effective in the treatment of
intrauterine pathologies, there is no consensus on the
effectiveness of hysteroscopic surgery in improving
the prognosis of subfertile women.

12. What do the guidelines say?
• The value of routine hysteroscopy prior to IVF ,
currently there is no conclusive evidence of its
benefit. The NICE guidelines suggest that women
should not be offered hysteroscopy on its own as part
of the initial investigation for infertility unless clinically
indicated
NICE Guidelines (2004).
• European Society of Human Reproduction and
Embryology guidelines for infertility investigations
suggest hysteroscopy could be useful for confirmation
and treatment of suspected uterine pathology .

13. Role of hysteroscopy prior to ET?
CONCLUSION
After hysteroscopy and subsequent IVF/ICSI-ET attempt using standard long
protocol, pregnancy rate were significantly higher compared with the previous
repeated IVF/ICSI attempts (35.8% versus 0%). Evaluation of endometrial integrity by
hysteroscopy in patients with repeated IVF/ICSI-ETs failure, before entering any
other fertilization procedures.

14. Should hysteroscopy be done before
the first cycle of ART?
• In a prospective analysis of 300 patients with
hysteroscopic examination and treatment of pathology
prior to a first IVF treatment cycle.
• The pregnancy rate in this group was compared with
the pregnancy rate in a retrospectively analyzed group
without hysteroscopy screening.
• In patients that did undergo a pre-IVF hysteroscopy,
the pregnancy rate was 38% compared with 18% in
patients without hysteroscopy .
Doldi et al.,2005

16. Hysteroscopy versus no hysteroscopy in patients
with at least two failed IVF attempts.
• Two randomized controlled trials reported exceptional
improvements in pregnancy rates after hysteroscopy screening and
instant treatment of detected pathology in patients after at least
two failed IVF attempts. Intervention resulted in a 9–13% increase
in clinical pregnancy rate after the subsequent IVF cycle (from 21.6
to 30.4% and from 26.2 to 39.6%, respectively).

17. Hysteroscopy in recurrent in-vitro fertilisation
failure (TROPHY): a multicentre, randomised
controlled trial
Dr Tarek El-Toukhy, Rudi Campo, MD ,April 2016
Multicentre, randomised controlled trial in eight hospitals in
the UK, Belgium, Italy, and the Czech Republic.
Outpatient hysteroscopy before IVF in women with a normal
ultrasound of the uterine cavity and a history of unsuccessful
IVF treatment cycles does not improve the livebirth rate.
Further research into the effectiveness of surgical correction of specific
uterine cavity abnormalities before IVF is warranted.

18. • The TROPHY study has now found such benefit to
be less than previously suggested.
• First, results showed that some abnormality of
the uterine cavity was found in 11% of the
patients having hysteroscopy.
• Second, outcome results following IVF showed no
significant difference between the two groups - a
live birth rate per patient of 31% in the
hysteroscopy group and 29% in the control group.

19. Hysteroscopy in women with implantation
failures after in vitro fertilization: Findings and
effect on subsequent pregnancy rates
• In all, 38% of the study population had abnormal
hysteroscopic findings and 22.2% of women with
abnormal hysteroscopic findings showed a
significantly increased CPR in subsequent IVF cycles.
Conclusion
• Women with repeated implantation failures after IVF
have a remarkably high possibility of achieving
pregnancy after hysteroscopic evaluation and
management of endometrial cavity pathology.
Fatima Aletebe Middle Eastern Fertility society journal 2010

20. Routine office hysteroscopy prior to ICSI and its
impact on assisted reproduction program
outcome: A randomized controlled trial
The incidence of pathologic abnormalities based on
hysteroscopic diagnosis was high especially with
repeated IVF failure.
Improvement in implantation and clinical pregnancy
rates were observed after office hysteroscopy prior to
ICSI.
So routine office hysteroscopy should be an essential
step of the infertility workup before ART even in
patients with normal HSG and /or TVS.
Hossam Eldin Shawki Middle Eastern fertility society journal 2012

23. • The two main problems that argue against the
case of hysteroscopy are: it is an invasive
procedure, and second, there is still an ongoing
debate about the real significance of the
observed intrauterine pathology on fertility.

24. Implementation of hysteroscopy in an infertility
clinic:
The one-stop uterine diagnosis and treatment
• With the new generation of instruments, it is possible
today to perform this one-stop diagnosis, in a most
comfortable and accurate way. Without the necessity
to use speculum or analgesia, ultrasound,
hysteroscopy, contrast sonography and even the
hysteroscopic or ultrasound guided endomyometrial
tissue sampling can be performed (Campo et al., 1999,
2005).
• This one stop approach provides with a high patient
compliance, all necessary information to make an
accurate diagnosis and to plan the correct therapeutic
approach.
R. Campo1,2,3, R. Meier,2, N. Dhont1, G.
Mestdagh1, W. Ombelet1 2014

25. • The one-stop uterine diagnosis starts with the transvaginal
ultrasound (TvU), followed by a fluid Trophy hysteroscopy using the
vagino-cervical atraumatic approach for which no speculum,
tenaculum or cervical preparation is used, no analgesia or
anaesthesia is necessary. Immediately after the hysteroscopy, a
second TvU is performed,taking advantage of the intracavitary fluid
for a contrast image of the uterus.
The one-stop uterine diagnosis and treatment

26. • Ultrasound as a first-line diagnostic tool to
evaluate the uterine reproductive capacities in
the infertile patient.
• Especially the high patient compliance, low
complication rate and the possibility of
enlarging the visual procedure with eye-
directed tissue sampling is seen as the most
important progress in the modern
hysteroscopic techniques.

28. But subtle lesions can only be
visualised by Hysteroscopy
Subtle lesions.(1) Focal hypervascularization, (2) Cavity deformation, (3) Mucosal elevation.

29. INDICATIONS
• Cervical canal problems
Stenosis/false passages
• Suspicion of any anatomical defect
• Suspicion of any intrauterine pathology
• Endometrial pathology
• Endometrial injury
• Second look hysteroscopy

30. COMPLICATIONS
• INJURY
– Mechanical
– Electrical
• FLUID OVERLOAD
• INFECTION
• BLEEDING
Incidence of Complications
The complication rate in diagnostic hysteroscopy is low and was estimated by
Lindemann (1989) to be 0.012% .
Complications from operative hysteroscopy are more common and potentially
more serious.

31. Take home message
• Uterine cavity evaluation is important.
• Preference especially non invasive method.
• TVS, HSG,Hysteroscopy various modalities.
• Hysteroscopy gold standard for Diagnostic and
therapeutic.
• Evidence building up on value of hysteroscopy in
recurrent implantation failures.
• Endometrial injury definitely improves outcome.
• Scope of primary hysteroscopy Pre IVF needs
further authentication.